Comparing Intramedullary Nails Versus Dynamic Hip Screws in the Treatment of Intertrochanteric Hip Fractures on Post-operative Rehabilitation Outcomes:A Systematic Review Protocol

Background: Intertrochanteric hip fractures are treated by fixation with either an intramedullary (IM) Nail or Dynamic Hip Screw (DHS). It is unknown whether one surgery type has better post-operative rehabilitative outcomes for the hip fracture population. This systematic review aims to compare post-operative rehabilitation outcomes of intertrochanteric hip fractures treated via IM Nails versus DHS. Methods: We will conduct a systematic review following the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. A search strategy will be developed, and the following databases will be searched: MEDLINE, EMBASE, Cochrane Library, and Web of Science. Two reviewers will perform a two-step screening process and data extraction of included studies. Any disagreement will be resolved with a discussion or a third reviewer. Risk of bias and the quality of the studies will also be assessed. A narrative synthesis will be used for the data analysis. Conclusion: This systematic review will provide evidence for orthopaedic surgeons and rehabilitation clinicians to further improve patient rehabilitation outcomes post-hip fracture surgery.


Background
Intertrochanteric hip fractures are treated by fixation with either an intramedullary (IM) Nail or Dynamic Hip Screw (DHS). In the literature, both intramedullary (IM) Nails and Dynamic Hip Screws (DHS) have shown favourable results. [1][2][3] The decision of whether to use IM Nail vs DHS is not consistently applied in practice. In principle, IM Nail is a stronger construct than the DHS fixation. 4 Therefore, many authors have suggested that DHS fixation can be used for most stable intertrochanteric fractures 5 but more unstable patterns should be treated by IM Nail. 6 Interestingly, several studies demonstrate that even the treatment of unstable fracture patterns using DHS has equal success rates of proper healing and therefore IM Nail fixation is not superior in stable or unstable fracture patterns. 7,8 Since both techniques have shown favourable results and the DHS is less costly, it might make sense that the less expensive implant be used more frequently. Despite this concept, orthopaedic surgeons tend to favor the use of IM Nail and their use has grown significantly over the past 20 years. 2,9 Although it is important to consider the "success" of surgery based on a fracture healing, there are also other considerations including operating room time, blood loss, length of stay, patient-reported outcomes, hospital discharge location, and rehabilitation success. We know that some hip fracture patients have difficulty returning to their pre-fracture level of function and multiple factors likely play a role. 10 When comparing the DHS and IM Nail, Bohl and colleagues found that patients being treated with an IM Nail were discharged on average, one day earlier than those who received the DHS as a treatment type. 1 Bienkowski and colleagues also found that patients treated with IM Nail fixation were more likely to recover the ability to ambulate well six months post-surgery compared with DHS patients (71% vs 33%, respectively). 11 However, most studies to date have focused primarily on health care utilization related outcomes 1,2,9,11,12 and to our knowledge, less research has specifically examined whether IM Nails or DHS fixation leads to better postoperative rehabilitation outcomes. Thus, we aim to synthesize the existing literature that compares post-operative rehabilitation outcomes of intertrochanteric hip fractures treated via IM Nails versus DHS. We will also describe the outcomes that are currently evaluated in the literature and identify gaps for future research.

Research Design and Methodology
We will conduct a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. 13 This protocol was prepared in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement. 13 This review is also registered with PROSPERO (CRD42022364556).

Eligibility Criteria
The inclusion and exclusion criteria are as follows: Population: intertrochanteric hip fractures. Interventions: intramedullary (IM) Nails. Comparison: Dynamic Hip Screws (DHS). Outcomes: rehabilitation (e.g, time to initiation of rehabilitation, functional outcomes, quality of life, rehabilitation length of stay, rehabilitation intensity/ frequency, type of rehabilitation, discharge destination), health utilization (e.g., return to the emergency room, readmission to hospital), and survival outcomes. Study designs: randomized controlled trials and non-randomized experimental studies (e.g., cohort, case-control, controlled before-and-after, interrupted-time-series, and controlled trials not using full randomization), qualitative or mixedmethods primary studies.

Search Strategy
The search strategy was developed by an information specialist and was peer-reviewed by another information specialist following the Peer Review of electronic search strategies (PRESS) guidelines. 14 The following databases will be searched: MEDLINE, EMBASE, Cochrane, and Web of Science. The MEDLINE search strategy can be found in Appendix 1. All citations will be imported into Covidence, 15 a systematic review management software, where duplicates will be removed.

Screening
Two reviewers (LK, CB) will perform a two-step screening process. Specifically, the two reviewers will independently screen titles and abstracts (level 1 screening) according to the pre-determined eligibility criteria. For the level 2 screening, the two reviewers will independently screen the full texts. Any disagreement will be resolved by a discussion or by a third reviewer (SP). The reasons for exclusion will be noted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. 13 We will manually search the reference lists of all the included studies and relevant systematic reviews. Relevant best practice guidelines will also be hand searched.

Data Extraction
Prior to starting the data extraction, we will pilot test our data extraction form in Microsoft Excel. Two reviewers (LK, CB) will independently extract the data from the eligible studies. This will include full reference, country, purpose, study design, type of participants, number of participants, theoretical approach, description of the intervention, data analysis, and study results/outcomes. Any disagreement will be discussed to reach an agreement.

Risk of Bias Assessment
The risk of bias of each study will be assessed independently by two reviewers. We will use the Cochrane risk-ofbias tool for randomized trials (RoB 2) 16 to assess the risk of bias in randomized trials and the Risk of Bias in nonrandomized studies of interventions (ROBINS-I) 17 to assess the risk of bias in non-randomized studies comparing two or more interventions. All conflicts will be resolved by a discussion or if needed, by a third reviewer (SP). We will not exclude any studies in our review based on their quality. We will present the studies' weaknesses if it has an overall impact on the data synthesis.

Quality of the Evidence
We will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework 18 to evaluate the quality of the body of evidence from studies. The risk of bias across studies will be assessed through evaluation of the publication bias using a funnel plot. A funnel plot will be constructed by plotting the effect estimates reported in each study against their effect sizes. Publication bias will be assessed if the included studies have a heterogeneous sample size and their study design and methodology do not differ considerably.

Data Synthesis
We will conduct a narrative data synthesis. Data will be grouped by settings, intervention type, outcome, and study design. All data tables will contain data on setting, intervention and control, study sample, patient characteristics, study design, outcome, and overall RoB. Where possible, a meta-analysis of results from randomized controlled studies and non-randomized studies will be carried out to estimate a summary measure of effect. Metaanalysis will be performed using Review Manager 5. 19 Conclusion This systematic review will provide evidence for orthopaedic surgeons and rehabilitation clinicians to further improve patient rehabilitation outcomes post-hip fracture surgery. This research will also identify gaps and provide recommendations to inform further work by determining which approach may provide better functional recovery for intertrochanteric hip fracture patients.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding was received from the Bruyère Academic Medical Organization (BAMO) Innovation fund.